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VALVE-SPARING ROOT REPLACEMENT IN PATIENTS WITH BICUSPID VS TRICUSPID AORTIC VALVES
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176 INCIDENCE, PREDICTORS, AND IMPACT OF BIOPROSTHETIC VALVE HEMODYNAMIC DETERIORATION FOLLOWING AORTIC VALVE REPLACEMENT E Salaun, H Mahjoub, N Girerd, F Dagenais, P Voisine, P Juni, S Mohammadi, D Kalavrouziotis, B Yanagawa, S Verma, M Clavel, P Pibarot
Canadian Journal of Cardiology Volume 33 2017
mismatch, high residual gradient, and/or transprosthetic regurgitation early after AVR 177 VALVE-SPARING ROOT REPLACEMENT IN PATIENTS WITH BICUSPID VS TRICUSPID AORTIC VALVES
Québec, Québec
M Ouzounian, C Feindel, C Manlhiot, C David, T David
BACKGROUND:
Toronto, Ontario
The occurrence of structural biological valve deterioration after aortic valve replacement (AVR) is generally defined by the need for reoperation due to valve failure. However, this approach significantly underestimates the incidence of structural valve deterioration. We intended to determine the incidence, predictors and impact of bioprosthesis (BP) valve hemodynamic deterioration (VHD) assessed by Doppler-echocardiography according to the postoperative time period. METHODS: A total of 1387 patients (62.2% male; 70.57.8 years old) were included in this retrospective study. A baseline echocardiography was performed at a median time of 4.1 (1.3e6.5) months post-AVR. Doppler-echocardiography follow-up was performed at least 2-years post-AVR in all patients, at least 5-years in 926 patients and at least 10-years in 385 patients. VHD was defined as: 10mmHg increase in mean transprosthetic gradient (MG) and/or worsening of transprosthetic regurgitation 1/3 grade from baseline to last echocardiography follow-up. RESULTS: Overall, VHD was identified in 428 patients (30.9%). The VHD occurred within the first 5 years in 181 (42.3%) patients and after 5 years in 247 (57.7%) patients. VHD (expressed as time-dependent variable) was a significant predictor of death (HR: 2.18, 95% CI: 1.86 to 2.57, p < 0.001) (Figure). Age at the date of first detection of VHD was not a predictor of VHD. Diabetes (HR: 1.33, 95% CI: 1.06 to 1.66, p¼0.01), post-surgery MG 15mmHg (HR: 1.30, 95% CI: 1.05 to 1.62, p¼0.02), severe prosthesisepatient mismatch (HR: 1.85, 95% CI: 1.12 to 2.87, p¼0.02) and type of BP (protector effect of stentless vs. BP, p < 0.001) were independently associated with VHD during follow-up. Predictors of early VHD identified (within the first 5-years post-AVR) were: diabetes (p¼0.01), active smoker status (p¼0.01), renal insufficiency (p¼0.01), post-surgery MG 15mmHg (p¼0.04), post-surgery mild transprosthetic regurgitation (p¼0.04) and type of BP (protector effect of stentless vs. stented BP, p¼0.003). Predictors of late VHD (i.e. after the 5 years) were: female sex (p¼0.03), use of coumadin (p¼0.007) and type of BP (stented vs. stenless, p < 0.001). CONCLUSION: The results of this large series reveals that VHD as documented by Doppler-echocardiography is frequent (30%) following AVR and is associated with 2.2 fold increase in mortality. The main factors associated with increased risk of VHD were female sex, diabetes, smoking, use of Coumadin, presence of severe prosthesis-patient
BACKGROUND:
We sought to compare the outcomes of patients undergoing aortic valve-sparing root replacement with bicuspid (BAV) vs. tricuspid (TAV) aortic valves. METHODS: A total of 408 consecutive patients (BAV, n¼47; TAV, n¼361) underwent valve-sparing root replacement from 1988 through 2012 at a single institution. Patients with BAV were younger (BAV: 40 13 vs. TAV: 48 15, p < 0.001), were less likely to have advanced heart failure (BAV: 0% vs. TAV: 17.5%, p¼0.007), and less likely to have Marfan syndrome (BAV: 8.5% vs. TAV: 44.3%, p < 0.001). Patients were followed prospectively with aortic root imaging for a median of 8.4 (5.4-12.9) years. The clinical follow-up data were complete and the echocardiographic studies were 98% complete during the most recent 3 years. The primary outcome of interest was freedom from mortality. Secondary outcomes of interest included (1) reoperation on the aortic valve and (2) the development of moderate to severe aortic insufficiency. Clinical outcomes between BAV and TAV patients were compared following stratification of patients into tertiles of the estimated propensity score. RESULTS: Reimplantation of the aortic valve was used in the majority of patients (BAV: 95.7% vs. TAV: 79.8%, p¼0.005); the remaining patients underwent the remodeling procedure. Primary cusp repair was required more often in patients with BAV (BAV: 79.6% vs. TAV: 40.4%, p < 0.001). Specifically, more patients with BAV required cusp plication (BAV: 77.3% vs. TAV: 33.3%, p < 0.001), whereas reinforcement of the free margin with Gore-Tex suture was similar between groups (BAV: 23.8% vs. TAV: 26.5%, p¼0.85). A total of 4 operative deaths occurred (BAV 0% vs. TAV 1.1%, p¼1). The frequency of all early complications was low and similar between groups. Longterm freedom from mortality was higher in the BAV group (p¼0.035). Cumulative rates of aortic valve reoperation were similar between groups (p¼0.93). Similarly, cumulative rates of moderate or severe aortic insufficiency were similar between groups (p¼0.24) (see Figure). Following stratification of patients into tertiles of risk based on a propensity score, long-term freedom from death, aortic valve reoperation, and moderate or severe aortic insufficiency were similar between groups. CONCLUSION: Although patients with BAV require more concomitant cusp repair, valve-sparing root replacement offers excellent clinical outcomes with both bicuspid and tricuspid valves.
Abstracts
178 THE LEARNING CURVE OF THORACIC AORTIC SURGERY WITH HYPOTHERMIC CIRCULATORY ARREST: A CUMULATIVE SUM ANALYSIS OF 348 OPERATIONS FROM THREE EARLY-CAREER SURGEONS A Mazine, A Ghoneim, L Stevens, I El Hamamsy, A Harrington, K Losenno, A Hassan, M Peterson, M Chu Toronto, Ontario BACKGROUND:
Several studies have investigated the relationship between institutional volumes and outcomes following aortic surgery. However, few have examined individual surgeons’ learning curves. Herein, we analyze the learning curve of three early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) across a spectrum of aortic reconstructive procedures. The aim of this study was to analyze the impact of the learning curve on short-term outcomes following aortic operations requiring HCA. METHODS: A total of 348 consecutive patients who underwent aortic reconstruction with HCA between 2008 and 2016 were analyzed for mortality and eight other complications (stroke, bleeding requiring reintervention, acute renal failure requiring dialysis, perioperative myocardial
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infarction, low cardiac output necessitating intra-aortic balloon pump, malignant arrhythmia, sternal dehiscence, and septic shock), subdivided into three consecutive time periods. This cohort represents the complete inaugural experience of three Canadian academic aortic surgeons. A cumulative sum (CUSUM) analysis was used to evaluate the learning curve with respect to predetermined 80% alert and 95% alarm boundary lines. RESULTS: Mean age was 6113 years, 30% were female and 24% were non-elective operations. Perioperative outcomes are presented in Table 1. Overall, operative mortality and stroke occurred in 13 (4%) and 12 (3%) patients, respectively. There was a reduction in the incidence of operative mortality over time (P1: 7 [6%], P2: 6 [5%], and P3: 0 [0%]; p¼0.017). Cumulative sum analysis revealed improvement in outcomes after w30 cases (Figure 1A). The learning curve was shorter for hemiarch replacement (20-25 cases) (Figure 1B) than for total arch replacement (30-35 cases) (Figure 1C). All surgeons remained within the 80% reassurance boundary throughout their experience, both for hemiarch and total arch or thoracoabdominal replacement. CONCLUSION: In conclusion, this study demonstrates that early-career surgeons can safely perform thoracic aortic operations with the use of HCA from the initiation of their practice. Improvements in safety are seen after a relatively short learning curve of approximately 30 cases. Overall operative mortality and incidence of adverse events compared favorably to published results from high-volume institutions with established expertise in thoracic aortic surgery. The CUSUM analysis method is valuable for monitoring competence in this type of surgery and could prove useful in structuring training programs.
176 INCIDENCE, PREDICTORS, AND IMPACT OF BIOPROSTHETIC VALVE HEMODYNAMIC DETERIORATION FOLLOWING AORTIC VALVE REPLACEMENT E Salaun, H Mahjoub, N Girerd, F Dagenais, P Voisine, P Juni, S Mohammadi, D Kalavrouziotis, B Yanagawa, S Verma, M Clavel, P Pibarot
Canadian Journal of Cardiology Volume 33 2017
mismatch, high residual gradient, and/or transprosthetic regurgitation early after AVR 177 VALVE-SPARING ROOT REPLACEMENT IN PATIENTS WITH BICUSPID VS TRICUSPID AORTIC VALVES
Québec, Québec
M Ouzounian, C Feindel, C Manlhiot, C David, T David
BACKGROUND:
Toronto, Ontario
The occurrence of structural biological valve deterioration after aortic valve replacement (AVR) is generally defined by the need for reoperation due to valve failure. However, this approach significantly underestimates the incidence of structural valve deterioration. We intended to determine the incidence, predictors and impact of bioprosthesis (BP) valve hemodynamic deterioration (VHD) assessed by Doppler-echocardiography according to the postoperative time period. METHODS: A total of 1387 patients (62.2% male; 70.57.8 years old) were included in this retrospective study. A baseline echocardiography was performed at a median time of 4.1 (1.3e6.5) months post-AVR. Doppler-echocardiography follow-up was performed at least 2-years post-AVR in all patients, at least 5-years in 926 patients and at least 10-years in 385 patients. VHD was defined as: 10mmHg increase in mean transprosthetic gradient (MG) and/or worsening of transprosthetic regurgitation 1/3 grade from baseline to last echocardiography follow-up. RESULTS: Overall, VHD was identified in 428 patients (30.9%). The VHD occurred within the first 5 years in 181 (42.3%) patients and after 5 years in 247 (57.7%) patients. VHD (expressed as time-dependent variable) was a significant predictor of death (HR: 2.18, 95% CI: 1.86 to 2.57, p < 0.001) (Figure). Age at the date of first detection of VHD was not a predictor of VHD. Diabetes (HR: 1.33, 95% CI: 1.06 to 1.66, p¼0.01), post-surgery MG 15mmHg (HR: 1.30, 95% CI: 1.05 to 1.62, p¼0.02), severe prosthesisepatient mismatch (HR: 1.85, 95% CI: 1.12 to 2.87, p¼0.02) and type of BP (protector effect of stentless vs. BP, p < 0.001) were independently associated with VHD during follow-up. Predictors of early VHD identified (within the first 5-years post-AVR) were: diabetes (p¼0.01), active smoker status (p¼0.01), renal insufficiency (p¼0.01), post-surgery MG 15mmHg (p¼0.04), post-surgery mild transprosthetic regurgitation (p¼0.04) and type of BP (protector effect of stentless vs. stented BP, p¼0.003). Predictors of late VHD (i.e. after the 5 years) were: female sex (p¼0.03), use of coumadin (p¼0.007) and type of BP (stented vs. stenless, p < 0.001). CONCLUSION: The results of this large series reveals that VHD as documented by Doppler-echocardiography is frequent (30%) following AVR and is associated with 2.2 fold increase in mortality. The main factors associated with increased risk of VHD were female sex, diabetes, smoking, use of Coumadin, presence of severe prosthesis-patient
BACKGROUND:
We sought to compare the outcomes of patients undergoing aortic valve-sparing root replacement with bicuspid (BAV) vs. tricuspid (TAV) aortic valves. METHODS: A total of 408 consecutive patients (BAV, n¼47; TAV, n¼361) underwent valve-sparing root replacement from 1988 through 2012 at a single institution. Patients with BAV were younger (BAV: 40 13 vs. TAV: 48 15, p < 0.001), were less likely to have advanced heart failure (BAV: 0% vs. TAV: 17.5%, p¼0.007), and less likely to have Marfan syndrome (BAV: 8.5% vs. TAV: 44.3%, p < 0.001). Patients were followed prospectively with aortic root imaging for a median of 8.4 (5.4-12.9) years. The clinical follow-up data were complete and the echocardiographic studies were 98% complete during the most recent 3 years. The primary outcome of interest was freedom from mortality. Secondary outcomes of interest included (1) reoperation on the aortic valve and (2) the development of moderate to severe aortic insufficiency. Clinical outcomes between BAV and TAV patients were compared following stratification of patients into tertiles of the estimated propensity score. RESULTS: Reimplantation of the aortic valve was used in the majority of patients (BAV: 95.7% vs. TAV: 79.8%, p¼0.005); the remaining patients underwent the remodeling procedure. Primary cusp repair was required more often in patients with BAV (BAV: 79.6% vs. TAV: 40.4%, p < 0.001). Specifically, more patients with BAV required cusp plication (BAV: 77.3% vs. TAV: 33.3%, p < 0.001), whereas reinforcement of the free margin with Gore-Tex suture was similar between groups (BAV: 23.8% vs. TAV: 26.5%, p¼0.85). A total of 4 operative deaths occurred (BAV 0% vs. TAV 1.1%, p¼1). The frequency of all early complications was low and similar between groups. Longterm freedom from mortality was higher in the BAV group (p¼0.035). Cumulative rates of aortic valve reoperation were similar between groups (p¼0.93). Similarly, cumulative rates of moderate or severe aortic insufficiency were similar between groups (p¼0.24) (see Figure). Following stratification of patients into tertiles of risk based on a propensity score, long-term freedom from death, aortic valve reoperation, and moderate or severe aortic insufficiency were similar between groups. CONCLUSION: Although patients with BAV require more concomitant cusp repair, valve-sparing root replacement offers excellent clinical outcomes with both bicuspid and tricuspid valves.
Abstracts
178 THE LEARNING CURVE OF THORACIC AORTIC SURGERY WITH HYPOTHERMIC CIRCULATORY ARREST: A CUMULATIVE SUM ANALYSIS OF 348 OPERATIONS FROM THREE EARLY-CAREER SURGEONS A Mazine, A Ghoneim, L Stevens, I El Hamamsy, A Harrington, K Losenno, A Hassan, M Peterson, M Chu Toronto, Ontario BACKGROUND:
Several studies have investigated the relationship between institutional volumes and outcomes following aortic surgery. However, few have examined individual surgeons’ learning curves. Herein, we analyze the learning curve of three early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) across a spectrum of aortic reconstructive procedures. The aim of this study was to analyze the impact of the learning curve on short-term outcomes following aortic operations requiring HCA. METHODS: A total of 348 consecutive patients who underwent aortic reconstruction with HCA between 2008 and 2016 were analyzed for mortality and eight other complications (stroke, bleeding requiring reintervention, acute renal failure requiring dialysis, perioperative myocardial
S109
infarction, low cardiac output necessitating intra-aortic balloon pump, malignant arrhythmia, sternal dehiscence, and septic shock), subdivided into three consecutive time periods. This cohort represents the complete inaugural experience of three Canadian academic aortic surgeons. A cumulative sum (CUSUM) analysis was used to evaluate the learning curve with respect to predetermined 80% alert and 95% alarm boundary lines. RESULTS: Mean age was 6113 years, 30% were female and 24% were non-elective operations. Perioperative outcomes are presented in Table 1. Overall, operative mortality and stroke occurred in 13 (4%) and 12 (3%) patients, respectively. There was a reduction in the incidence of operative mortality over time (P1: 7 [6%], P2: 6 [5%], and P3: 0 [0%]; p¼0.017). Cumulative sum analysis revealed improvement in outcomes after w30 cases (Figure 1A). The learning curve was shorter for hemiarch replacement (20-25 cases) (Figure 1B) than for total arch replacement (30-35 cases) (Figure 1C). All surgeons remained within the 80% reassurance boundary throughout their experience, both for hemiarch and total arch or thoracoabdominal replacement. CONCLUSION: In conclusion, this study demonstrates that early-career surgeons can safely perform thoracic aortic operations with the use of HCA from the initiation of their practice. Improvements in safety are seen after a relatively short learning curve of approximately 30 cases. Overall operative mortality and incidence of adverse events compared favorably to published results from high-volume institutions with established expertise in thoracic aortic surgery. The CUSUM analysis method is valuable for monitoring competence in this type of surgery and could prove useful in structuring training programs.